Subarachnoid hemorrhage medical therapy

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AHA/ASA Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage (2012)

Risk Factors/Prevention
Natural History/Outcome
Clinical Manifestations/Diagnosis
Medical Measures to Prevent Rebleeding
Surgical and Endovascular Methods
Hospital Characteristics/Systems of Care
Anesthetic Management
Cerebral Vasospasm and DCI
Hydrocephalus
Seizures Associated With aSAH
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Sara Mehrsefat, M.D. [3]

Overview

The first priority is stabilization of the patient. In those with a depressed level of consciousness, intubation and mechanical ventilation may be required. Blood pressure, pulse, respiratory rate and Glasgow Coma Scale are monitored frequently. Once the diagnosis is confirmed, admission to an intensive care unit (ICU) may be considered preferable, especially given that 15% have a further episode (rebleeding) in the first hours after admission. Nutrition is an early priority, with oral or nasogastric tube feeding being preferable over parenteral routes. Analgesia (pain control) is generally restricted to non-sedating agents, as sedation would interfere with the monitoring of the level of consciousness. There is emphasis on the prevention of complications; for instance, vasospasm with Nimodipine and other modalities and deep vein thrombosis with compression stockings.

Medical Therapy

The first priority is stabilization of the patient. In those with a depressed level of consciousness, intubation and mechanical ventilation may be required. Blood pressure, pulse, respiratory rate and Glasgow Coma Scale are monitored frequently. Once the diagnosis is confirmed, admission to an intensive care unit (ICU) may be considered preferable, especially given that 15% have a further episode (rebleeding) in the first hours after admission. Nutrition is an early priority, with oral or nasogastric tube feeding being preferable over parenteral routes. Analgesia (pain control) is generally restricted to non-sedating agents, as sedation would interfere with the monitoring of the level of consciousness. There is emphasis on the prevention of complications.

Medical Condition Management
First 24h of admission
  • Intensive care unit admission (constant hemodynamic and neurologic monitoring)
  • Endotracheal intubation in patient with:
  • Deep venous thrombosis (DVT) prophylaxis (pneumatic compression stocking)
  • Intravenous fluid administration
    • Euvolemia
    • Normal electrolyte balance (avoid hyponatremia)
  • Antithrombotic discontinuation
Increased intracranial pressure (ICP)
  • Place a ventriculostomy
  • Osmotic therapy and diuresis
  • Avoid hyperventilation hyperventilation can result in exacerbate vasospasm
Blood pressure control
  • No clear targeted blood pressure is defined
  • Decrease in systolic blood pressure to <160mm Hg
  • Preferred regimen
  • Decrease in systolic blood pressure to <160mm Hg
  • Nitroprusside or nitroglycerin should be avoided (possible increase intracranial pressure)
Antiepileptic drug therapy
  • May be considered in the immediate posthemorrhagic period
  • The routine long-term use of anticonvulsants is not recommend unless in the following conditions:
    • Prior seizure
    • Intracerebral hematoma
    • Intractable hypertension
    • Infarction
    • Aneurysm at the middle cerebral artery
Antiepileptic drug therapy
Vasospasm

Prevention of Vasospasm

Vasospasm is a serious complication of SAH. It may be seen in 50% of SAH patients studied with angiography, and is symptomatic roughly 30% of the time. This condition can be verified by transcranial doppler or cerebral angiography, and can cause ischemic brain injury that can cause permanent brain damage, and if severe can be fatal. Nimodipine, an oral calcium channel blocker, has been shown to reduce the chance of a bad outcome, even if it does not significantly reduce the amount of angiographic vasospasm.[1][2]

Follow-Up

A patient who recovers without immediate intervention may receive follow-up angiography to identify aneurysms which may be amenable to either surgical clipping or endovascular coiling to prevent recurrent episodes of SAH.

Contraindicated medications

Subarachnoid hemorrhage is considered an absolute contraindication to the use of the following medications:

2012 AHA/ASA Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage[3]

Management of Cerebral Vasospasm and DCI After aSAH: Recommendations

Class I
"1. Oral nimodipine should be administered to all patients with aSAH† (Level of Evidence: A)"
"2. Maintenance of euvolemia and normal circulating blood volume is recommended to prevent DCI (Level of Evidence: B)"
"3. Induction of hypertension is recommended for patients with DCI unless blood pressure is elevated at baseline or cardiac status precludes it (Level of Evidence: B)"

†It should be noted that this agent has been shown to improve neuroogical outcomes but not cerebral vasospasm. The value of other calcium antagonists, whether administered orally or intravenously, remains uncertain.

Class III (Harm)
"1. Prophylactic hypervolemia or balloon angioplasty before the development of angiographic spasm is not recommended (Level of Evidence: B)"
Class IIa
"1. Transcranial Doppler is reasonable to monitor for the development of arterial vasospasm (Level of Evidence: B)"
"2. Perfusion imaging with CT or magnetic resonance can be useful to identify regions of potential brain ischemia (Level of Evidence: B)"
"3. Cerebral angioplasty and/or selective intra-arterial vasodilator therapy is reasonable in patients with symptomatic cerebral vasospasm, particularly those who are not rapidly responding to hypertensive therapy (Level of Evidence: B)"

Management of Seizures Associated With aSAH: Recommendations

Class III (Harm)
"1. The routine long-term use of anticonvulsants is not recommended (Level of Evidence: B)"
Class IIb
"1. The use of prophylactic anticonvulsants may be considered in the immediate posthemorrhagic period (Level of Evidence: B)"
"2. The routine long-term use of anticonvulsants may be considered for patients with known risk factors for delayed seizure disorder, such as prior seizure, intracerebral hematoma, intractable hypertension, infarction, or aneurysm at the middle cerebral artery (Level of Evidence: B)"

Management of Hydrocephalus Associated With aSAH: Recommendations

Class I
"1. aSAH-associated acute symptomatic hydrocephalus should be managed by cerebrospinal fluid diversion (EVD or lumbar drainage, depending on the clinical scenario) (Level of Evidence: B)"
"2. aSAH-associated chronic symptomatic hydrocepha- lus should be treated with permanent cerebrospinal fluid diversion (Level of Evidence: C)"
Class III (Harm)
"1. Weaning EVD over >24 hours does not appear to be effective in reducing the need for ventricular shunting (Level of Evidence: B)"
"2. Routine fenestration of the lamina terminalis is not useful for reducing the rate of shunt-dependent hydrocephalus and therefore should not be routinely performed. (Level of Evidence: B)"

Management of Cerebral Vasospasm and DCI After aSAH: Recommendations

Class I
"1. Oral nimodipine should be administered to all patients with aSAH† (Level of Evidence: A)"
"2. Maintenance of euvolemia and normal circulating blood volume is recommended to prevent DCI (Level of Evidence: B)"
"3. Induction of hypertension is recommended for patients with DCI unless blood pressure is elevated at baseline or cardiac status precludes it (Level of Evidence: B)"

†It should be noted that this agent has been shown to improve neuroogical outcomes but not cerebral vasospasm. The value of other calcium antagonists, whether administered orally or intravenously, remains uncertain.

Class III (Harm)
"1. Prophylactic hypervolemia or balloon angioplasty before the development of angiographic spasm is not recommended (Level of Evidence: B)"
Class IIa
"1. Transcranial Doppler is reasonable to monitor for the development of arterial vasospasm (Level of Evidence: B)"
"2. Perfusion imaging with CT or magnetic resonance can be useful to identify regions of potential brain ischemia (Level of Evidence: B)"
"3. Cerebral angioplasty and/or selective intra-arterial vasodilator therapy is reasonable in patients with symptomatic cerebral vasospasm, particularly those who are not rapidly responding to hypertensive therapy (Level of Evidence: B)"

References

  1. Allen GS, Ahn HS, Preziosi TJ; et al. (1983). "Cerebral arterial spasm--a controlled trial of nimodipine in patients with subarachnoid hemorrhage". N. Engl. J. Med. 308 (11): 619–24. PMID 6338383.
  2. Dorhout Mees S, Rinkel G, Feigin V; et al. (2007). "Calcium antagonists for aneurysmal subarachnoid haemorrhage". Cochrane database of systematic reviews (Online) (3): CD000277. doi:10.1002/14651858.CD000277.pub3. PMID 17636626.
  3. Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage http://stroke.ahajournals.org/content/early/2012/05/03/STR.0b013e3182587839

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